Take Home Message: A
novel clinical risk score developed for the acutely concussed pediatric
population has a modest ability to discriminate between those at low, medium,
or high risk for persistent postconcussion symptoms at 28 days.

After
a concussion, nearly a third of pediatric patients experience somatic,
cognitive, psychological, and behavioral symptoms for longer than 28 days,
which is often referred to as persistent postconcussion symptoms (PPCS). Unfortunately,
medical professionals lack a validated tool to identify a young athlete at risk
for PPCS. Therefore, the authors of this multi-center prospective cohort study
aimed to derive and validate a clinical risk score for PPCS among children
presenting to an emergency department. The study included 2,584 patients (ages
5-17 [median 12 years old]) who were diagnosed with a concussion within 48
hours at 1 of 9 emergency departments (within the Pediatric Emergency Research
Canada Network). All patients underwent
a standardized concussion evaluation (demographic data, medical and injury
history, post-concussion symptominventory,
SCAT3). The authors followed
the patients using electronic surveys (post-concussion symptom inventory) at 7,
14, and 28 days after injury. Patients recruited during August 2013 to
September 2014 were placed in the derivation group, and those recruited during
October 2014 to June 2015 were included in the validation cohort. Thirty-one
percent (801 patients) of the derivation and 30% (501 patients) of the
validation reported PPCS. The authors developed a 9-factor PPCS risk score
model using the clinical variables from initial evaluation and follow up survey
(female sex, age of 13 or older, physician diagnosed migraine history, prior
concussion with symptoms lasting longer than 1 week, headache, sensitivity to
noise, fatigue, answering questions slowly, and 4 or more errors on the tandem
stance during the Balance Error Scoring System Test). A score of 0-3 determined
low risk, 6-9 medium risk, and 10-12 was high risk for PPCS. The discrimination
of this model to detect PCSS risk was modest compared with physician judgment
in predicting PCSS. For the low-risk patients the sensitivity was 94% and the
specificity was 18%. For the high-risk patients the sensitivity was 20% and the
specificity was 93%.

The
authors assessed a large, diverse cohort of pediatric patients presenting at an
emergency department with an acute concussion, and determined a PPCS risk score
with a modest ability to discriminate between those at low, medium, or high
risk for PPCS compared to physician judgment. This is the first survey of its
kind to determine a risk score for PPCS. The survey is affordable, and easy for
the patient and parent to answer. Additionally, it provides the medical
professional with an easy to interpret score for PPCS risk (low, middle, high).
Many of these factors are already collected during a standard concussion assessment.
The authors acknowledged that more research needs to be done to refine this
score before it is ready for clinical use. It is reassuring however that these
robust findings complement previous research, which found several of these
factors to be associated with prolonged recovery, such as, migraine history, or
symptoms lasting more than 1 week. Therefore, it seems intuitive that this
would be a valid way of assessing risk. The pediatric population takes longer
to recovery than the adult population, which puts these patients at risk for
returning to physical activity sooner than they should. Knowing the risk of
PCSS would be helpful for medical professionals to monitor and manage a
concussion more efficiently. While it may take time to optimize this risk
scores clinicians should be aware of the factors identified in this study as
increasing the risk of PPCS. When a patient has more than one of these risk
factors it may be important to discuss with the patient the risk of PPCS.

Questions for Discussion:
Would you use a clinical risk score survey? Do the factors included in the
clinical risk score align with what you see in your concussed patients with
prolong recovery?

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